The U.S. health care system continues to make remarkable strides in the treatment of formerly untreatable forms of cancer and many other diseases. (See “2015 Win–Loss Scoreboard.”) People who can afford to do so travel from all over the world to see our best surgeons and diagnosticians. However, we are still failing to provide essential care to some of our most vulnerable populations.
In the nearly six years since the Affordable Care Act (ACA) became law, we've seen a significant drop in the uninsured rate (from almost 16% before the ACA to about 9%). But with rising income inequality, many Americans—including millions with full-time jobs, the “working poor”—are still struggling to afford secure shelter, education, transportation, and health care. Such socioeconomic instability is a major contributor to public health problems such as substance abuse; violence toward intimate partners, the elderly, and children; mental illness and suicide; and the high prevalence of chronic diseases like type 2 diabetes.
Nurses in every practice setting witness the negative physical and psychological effects of these often-interrelated public health problems. Meanwhile, drug prices continue to rise, insurance companies transfer a greater share of costs to consumers—some deductibles are now so high that they are deterring the use of insurance plans—and many vulnerable populations face gaps in coverage, especially in states that did not expand Medicaid eligibility under the ACA.
Violence. It's easy to feel overwhelmed by regular reports of new mass shootings, and in the past several years, the frequency of such shootings has in fact increased. But only a small percentage of annual gun deaths in the United States are from mass shootings. The Centers for Disease Control and Prevention (CDC) reports a small but steady increase in gun deaths per year (at nearly 34,000, there are now as many firearm-related deaths as deaths from motor vehicle accidents).
Over 11,000 of the more than 16,000 homicides in the United States each year are committed with guns. However, the biggest contributor to the recent increase in gun deaths in this country is suicide.
Suicide is now the 10th leading cause of death in the United States overall. The CDC recently reported significant increases in suicide rates among certain groups, especially white middle-aged men, who now account for over 70% of all suicides in the United States. Slightly more than half of the 41,000 suicide deaths in 2013 were firearm related.
IPV and elder abuse. Other types of violence that affect the vulnerable and often stay unreported and invisible to the public include
- an estimated 12 million victims per year of intimate partner violence (IPV) such as physical violence, rape, and stalking, the majority of whom are women.
- increasing numbers of older Americans suffering abuse or neglect. According to a review published in the November 12, 2015, New England Journal of Medicine, elder abuse affects at least 10% of older Americans, whether they are living in the community or in nursing homes, and probably many more because of inadequate screening and reporting. As the percentage of the population over 65 continues to increase and more family caregivers find themselves overwhelmed by the demands of caring for family members with dementia or significant physical impairment, nurses will need to provide resources to help stressed caregivers and know how to identify and report the signs of potential elder abuse and neglect.
Mental illness: continuing stigma, inadequate treatment access. According to recent data, each year one in five Americans experiences mental illness and one in 25 has at least one serious episode of mental illness that substantially compromises important life activities. While the media regularly reports on the epidemic of prescription drug and opiate abuse, less often reported is that, according to a 2014 report from the Substance Abuse and Mental Health Services Administration, more than 50% of the more than 20 million U.S. adults with a substance use disorder also suffer from a mental illness. Veterans are especially at risk for certain types of mental illness. According to the Department of Veterans Affairs, from 10% to 30% (depending on the conflict fought in) of veterans will suffer posttraumatic stress disorder, a condition that is often accompanied by depression or substance abuse. Many others face a range of negative effects from traumatic brain injury.
The Mental Health Parity and Addiction Equity Act of 2008, which the ACA applied to all marketplace individual and small business health insurance plans, required plans to provide mental health and substance abuse treatment. But enforcement has been weak, and access to affordable mental health care remains nonexistent for many. A recent survey by the National Alliance on Mental Illness found that 29% of patients with insurance were denied mental health care because it did not meet “medical necessity” criteria. In both private health plans and ACA-related plans, nearly a quarter of patients were unable to find a provider within the plan's network. Treatment options in the mental health system, meanwhile, are fragmented, and surveys suggest that the stigma of mental health issues remains high, leading many people who are most in need to forego seeking care. And while people with mental illness also have an increased risk of developing preventable chronic illnesses such as type 2 diabetes, they are less likely to be screened for such conditions or to properly manage them.
The growing burden of chronic illness. In November 2015 the CDC reported that, despite widespread efforts to address the problem, the obesity rate in the United States has grown in the past five years and is now at almost 37%.
Chronic illnesses such as arthritis and heart disease are costing billions in care and straining health care resources. The care of an aging population, particularly older adults with dementia, is also a growing concern. A recent study in the Annals of Internal Medicine found that the cost of dementia care for Medicare patients in the last five years of life far surpassed that of heart disease or cancer, averaging $287,000 per person.
Smart, savvy nurses at every level and in every setting will need to be resourceful and committed if patients are to get the care they need. As strategies to address these public health problems are negotiated by politicians, professional organizations, citizens, and well-funded lobbyists, the nursing profession will continue to take practical steps to promote and implement improved hospital discharge practices, adequate nurse staffing, screening for and reporting of elder abuse and IPV, an understanding of addiction as a treatable and preventable disease, and access to quality care for all Americans, including the mentally ill.—Jacob Molyneux, senior editor